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Contents Program Information Appendix 1 - AHMAC Appendix 2 - Drugs Covered by the Program Appendix 3 - Agreed Prices
Appendix 4 - Patient Eligibility Criteria Appendix 5 - Certification Appendix 6 - Community prescribers of AIDs & Hep C medications Appendix 7 - Auditing Requirements Appendix 8 - Claiming Procedures

Appendix 3: Agreed Prices

Public hosp. Drug Name Form and Strength Brand Name Maximum Quantity Number of Repeats Pack Size Commonwealth Dispensed Price for Maximum Quantity 
5601T ABACAVIR Tablet 300mg Ziagen 120 5 60  $       564.00 
5602W ABACAVIR Oral solution 20mg (base) per mL, 240mL Ziagen 8 5 1  $       657.12 
5603X ABACAVIR SULFATE with LAMIVUDINE Tablet 600 mg (base)-300 mg Kivexa 60 5 30  $    1,128.00 
5604Y ABACAVIR SULFATE with LAMIVUDINE and ZIDOVUDINE Tablet 300 mg (base)-150 mg-300 mg Trizivir 120 5 60  $    1,704.00 
5605B ABATACEPT* Powder for I.V. infusion 250 mg Orencia 1 0 1  $       504.43 
9661L ADALIMUMAB* Injection 20mg in 0.4mL pre-filled syringe Humira 2 0 1  $    1,630.00
9662M ADALIMUMAB* Injection 40mg in 0.8mL pre-filled syringe Humira 2 0 1  $    1,630.00
9663N ADALIMUMAB* Injection 40mg in 0.8mL pre-filled syringe Humira 2 0 1  $    1,630.00
5606C ADEFOVIR DIPIVOXIL Tablet 10 mg Hepsera 60 5 30  $    1,250.00 
5607D AMBRISENTAN* Tablet 5 mg Volibris 30 0 30  $    4,035.00 
5608E AMBRISENTAN* Tablet 10 mg Volibris 30 0 30  $    4,035.00 
5609F APOMORPHINE HYDROCHLORIDE Injection 20 mg in 2 mL Apomine 5 0 5  $         77.86 
5610G APOMORPHINE HYDROCHLORIDE Injection 50 mg in 5 mL Apomine 5 0 5  $       194.65 
5611H APOMORPHINE HYDROCHLORIDE Solution for subcutaneous infusion 50 mg in 10 mL pre-filled syringe Apomine PFS 5 0 5  $       194.65 
5612J ATAZANAVIR Capsule 300 mg (as sulfate) Reyataz 60 5 30  $    1,043.82 
5613K ATAZANAVIR Capsule 150 mg (as sulfate) Reyataz 120 5 60  $    1,043.82 
5614L ATAZANAVIR Capsule 200 mg (as sulfate) Reyataz 120 5 60  $    1,391.76 
5615M ATAZANAVIR Capsule 100 mg (as sulfate) Reyataz 120 5 60  $       695.88 
9597D AZACITIDINE* Powder for injection 100mg Vidaza 14 2 1 $     7,700.00
9598E AZACITIDINE* Powder for injection 100mg Vidaza 14 5 1 $     7,700.00
5616N AZITHROMYCIN Tablet 600 mg (as dihydrate) Zithromax 16 5 8  $      113.96 
5617P BACLOFEN Intrathecal injection 10 mg in 5 mL Lioresal Intrathecal 10 0 1  $    1,483.70 
5618Q BOSENTAN MONOHYDRATE* Tablet 62.5 mg (base) Tracleer 60 0 60  $    4,035.00 
5619R BOSENTAN MONOHYDRATE* Tablet 125 mg (base) Tracleer 60 0 60  $    4,035.00
5620T CIDOFOVIR Solution for I.V. infusion 375 mg (anhydrous) in 5 mL single use vial Vistide 4 3 1  $    3,600.00 
5621W CINACALCET HYDROCHLORIDE Tablet 30 mg (base) Sensipar 56 5 28  $       593.72 
5622X CINACALCET HYDROCHLORIDE Tablet 60 mg (base) Sensipar 56 5 28  $    1,187.44
5623Y CINACALCET HYDROCHLORIDE Tablet 90 mg (base) Sensipar 56 5 28  $    1,781.16 
5624B CLARITHROMYCIN Tablet 500 mg Klacid 100 2 100  $       68.63
5625C CLARITHROMYCIN Tablet 250 mg Klacid 100 2 100  $       34.31
5626D CLOZAPINE Tablet 50 mg Clopine 50 100 0 100  $      135.54
5627E CLOZAPINE Tablet 200 mg Clopine 200 100 0 100  $      508.25
5628F CLOZAPINE Tablet 25 mg Clozaril 25 100 0 100  $       67.76 
5628F CLOZAPINE Tablet 25 mg Clopine 25 100 0 100  $       67.76
5629G CLOZAPINE Tablet 100 mg Clozaril 100 100 0 100  $      254.12
5629G CLOZAPINE Tablet 100 mg Clopine 100 100 0 100  $      254.12
5630H CLOZAPINE Oral liquid 50 mg per mL, 100 mL Clopine Suspension 1 0 1  $       135.00 
5631J CYCLOSPORIN Solution concentrate for I.V. infusion 50 mg in 1 mL Sandimmun 10 0 10  $        54.10 
5632K CYCLOSPORIN Capsule 10 mg Neoral 10 120 5 60  $        74.40 
5633L CYCLOSPORIN Oral liquid 100 mg per mL, 50 mL Neoral 4 5 1  $    1,263.16 
5634M CYCLOSPORIN Capsule 25 mg Cicloral 120 5 30  $      153.56 
5634M CYCLOSPORIN Capsule 25 mg Neoral 25 120 5 30  $      153.56 
5635N CYCLOSPORIN Capsule 50 mg Cicloral 120 5 30  $      319.52 
5635N CYCLOSPORIN Capsule 50 mg Neoral 50 120 5 30  $      319.52 
5636P CYCLOSPORIN Capsule 100 mg Cicloral 120 5 30  $       651.08 
5636P CYCLOSPORIN Capsule 100 mg Neoral 100 120 5 30  $       651.08 
5637Q DARBEPOETIN ALFA Injection 10 micrograms in 0.4 mL pre-filled syringe Aranesp 8 5 4  $       356.08 
5638R DARBEPOETIN ALFA Injection 20 micrograms in 0.5 mL pre-filled syringe Aranesp 8 5 4  $       670.62 
5639T DARBEPOETIN ALFA Injection 30 micrograms in 0.3 mL pre-filled syringe Aranesp 8 5 4  $       917.46 
5640W DARBEPOETIN ALFA Injection 40 micrograms in 0.4 mL pre-filled syringe Aranesp 8 5 4  $    1,113.60 
5641X DARBEPOETIN ALFA Injection 50 micrograms in 0.5 mL pre-filled syringe Aranesp 8 5 4  $    1,376.78 
5642Y DARBEPOETIN ALFA Injection 60 micrograms in 0.3 mL pre-filled syringe Aranesp 8 5 4  $    1,616.66 
5643B DARBEPOETIN ALFA Injection 150 micrograms in 0.3 mL pre-filled syringe Aranesp 8 5 4  $    3,904.50 
5644C DARBEPOETIN ALFA Injection 80 micrograms in 0.4 mL pre-filled syringe Aranesp 8 5 4  $    2,128.00 
5645D DARBEPOETIN ALFA Injection 20 micrograms in 0.5 mL pre-filled injection pen Aranesp SureClick 8 5 1  $       670.64 
5646E DARBEPOETIN ALFA Injection 40 micrograms in 0.4 mL pre-filled injection pen Aranesp SureClick 8 5 1  $    1,113.60 
5647F DARBEPOETIN ALFA Injection 60 micrograms in 0.3 mL pre-filled injection pen Aranesp SureClick 8 5 1  $    1,616.64 
5648G DARBEPOETIN ALFA Injection 80 micrograms in 0.4 mL pre-filled injection pen Aranesp SureClick 8 5 1  $    2,128.00 
5649H DARBEPOETIN ALFA Injection 100 micrograms in 0.5 mL pre-filled injection pen Aranesp SureClick 8 5 1  $    2,620.48 
5650J DARBEPOETIN ALFA Injection 150 micrograms in 0.3 mL pre-filled injection pen Aranesp SureClick 8 5 1  $    3,904.48 
5651K DARBEPOETIN ALFA Injection 100 micrograms in 0.5 mL pre-filled syringe Aranesp 8 5 4  $    2,620.50 
5652L DARUNAVIR Tablet 300 mg (as ethanolate) Prezista 240 5 120  $    2,097.42 
5653M DARUNAVIR Tablet 150 mg (as ethanolate) Prezista 240 5 240  $    1,048.71 
5821J DARUNAVIR Tablet 400 mg (as ethanolate) Prezista 120 5 60 $    1,398.28 
5654N DEFERASIROX Tablet 125 mg (dispersible) Exjade 168 5 28  $    1,401.48 
5655P DEFERASIROX Tablet 250 mg (dispersible) Exjade 168 5 28  $    2,802.90 
5656Q DEFERASIROX Tablet 500 mg (dispersible) Exjade 168 5 28  $    5,605.80 
5657R DEFERIPRONE Tablet 500 mg Ferriprox 600 5 100  $    2,703.36 
5658T DEFERIPRONE Oral solution 100 mg per mL, 250 mL Ferriprox 5 5 1  $    1,126.40 
5661Y DESFERRIOXAMINE MESYLATE Powder for injection 2 g Hospira Pty Limited 60 5 1  $   2,235.00 
5661Y DESFERRIOXAMINE MESYLATE Powder for injection 2 g Desferal 2 g 60 5 1  $   2,235.00 
5662B DESFERRIOXAMINE MESYLATE Powder for injection 500 mg Hospira Pty Limited 400 5 10  $   3,725.60  
5662B DESFERRIOXAMINE MESYLATE Powder for injection 500 mg Desferal 500 mg 400 5 10  $   3,725.60  
5663C DIDANOSINE Capsule 125 mg (containing enteric coated beadlets) Videx EC 60 5 30  $       280.86 
5664D DIDANOSINE Capsule 200 mg (containing enteric coated beadlets) Videx EC 60 5 30  $       326.80 
5665E DIDANOSINE Capsule 250 mg (containing enteric coated beadlets) Videx EC 60 5 30  $       408.48 
5666F DIDANOSINE Capsule 400 mg (containing enteric coated beadlets) Videx EC 60 5 30  $       653.58 
5667G DISODIUM PAMIDRONATE Concentrated injection 15 mg in 5 mL Pamisol 4 2 1  $      209.92 
5668H DISODIUM PAMIDRONATE Concentrated injection 30 mg in 10 mL Pamisol 2 2 1  $      209.92 
5669J DISODIUM PAMIDRONATE Concentrated injection 60 mg in 10 mL Pamisol 1 2 1  $      209.90 
5670K DISODIUM PAMIDRONATE Concentrated injection 90 mg in 10 mL Pamisol 1 11 1  $      314.85 
5701C DISODIUM PAMIDRONATE Injection set containing 4 vials powder for I.V. infusion 15 mg and 4 ampoules solvent 5 mL Aredia 15 mg 1 2 1  $      209.91 
5702D DISODIUM PAMIDRONATE Injection set containing 2 vials powder for I.V. infusion 30 mg and 2 ampoules solvent 10 mL Aredia 30 mg 1 2 1  $      209.91 
5703E DISODIUM PAMIDRONATE Injection set containing 1 vial powder for I.V. infusion 90 mg and 1 ampoule solvent 10 mL Aredia 90 mg 1 11 1  $      314.85 
5704F DORNASE ALFA Solution for inhalation 2.5 mg (2,500 units) in 2.5 mL Pulmozyme 60 5 30  $    2,360.00 
5705G DOXORUBICIN HYDROCHLORIDE, PEGYLATED LIPOSOMAL Suspension for I.V. infusion 20 mg in 10 mL Caelyx 4 5 1  $    2,491.96 
5706H EFAVIRENZ Tablet 600 mg Stocrin 60 5 30  $       905.28 
5707J EFAVIRENZ Oral solution 30 mg per mL, 180 mL Stocrin 7 5 1  $       950.53 
5708K EFAVIRENZ Tablet 200 mg Stocrin 180 5 90  $       905.28 
5825N ELTROMBOPAG* Tablet 25mg (as olamine) Revolade 28 5 28  $       1,512.00 
5826P ELTROMBOPAG* Tablet 50mg (as olamine) Revolade 28 5 28  $       3,024.00 
5709L EMTRICITABINE Capsule 200 mg Emtriva 60 5 30  $       564.00 
5710M ENFUVIRTIDE Pack containing 60 vials powder for injection 90 mg with 60 vials water for injections 1.1 mL (with syringes and swabs) Fuzeon 2 5 1  $    4,426.00 
5711N ENTECAVIR MONOHYDRATE Tablet 0.5 mg Baraclude 60 5 30  $       768.60 
5712P ENTECAVIR MONOHYDRATE Tablet 1 mg Baraclude 60 5 30  $    1,250.00 
5713Q EPOETIN ALFA Injection 20,000 units in 0.5 mL pre-filled syringe Eprex 20,000 12 5 6  $    3,876.00 
5714R EPOETIN ALFA Injection 1,000 units in 0.5 mL pre-filled syringe Eprex 1000 12 5 6  $       279.30 
5715T EPOETIN ALFA Injection 5,000 units in 0.5 mL pre-filled syringe Eprex 5000 12 5 6  $    1,057.34 
5716W EPOETIN ALFA Injection 6,000 units in 0.6 mL pre-filled syringe Eprex 6000 12 5 6  $    1,255.14 
5717X EPOETIN ALFA Injection 8,000 units in 0.8 mL pre-filled syringe Eprex 8000 12 5 6  $    1,627.92 
5718Y EPOETIN ALFA Injection 40,000 units in 1 mL pre-filled syringe Eprex 40,000 2 5 1  $    1,254.00 
5719B EPOETIN ALFA Injection 2,000 units in 0.5 mL pre-filled syringe Eprex 2000 12 5 6  $       516.80 
5720C EPOETIN ALFA Injection 3,000 units in 0.3 mL pre-filled syringe Eprex 3000 12 5 6  $       666.90 
5721D EPOETIN ALFA Injection 4,000 units in 0.4 mL pre-filled syringe Eprex 4000 12 5 6  $       849.30 
5722E EPOETIN ALFA Injection 10,000 units in 1 mL pre-filled syringe Eprex 10000 12 5 6  $    1,970.30 
5724G EPOETIN BETA Injection 2,000 units in 0.3 mL pre-filled syringe NeoRecormon 12 5 6  $       516.80 
5725H EPOETIN BETA Injection 3,000 units in 0.3 mL pre-filled syringe NeoRecormon 12 5 6  $       666.90 
5726J EPOETIN BETA Injection 4,000 units in 0.3 mL pre-filled syringe NeoRecormon 12 5 6  $       849.30 
5727K EPOETIN BETA Injection 5,000 units in 0.3 mL pre-filled syringe NeoRecormon 12 5 6  $    1,057.36 
5728L EPOETIN BETA Injection 6,000 units in 0.3 mL pre-filled syringe NeoRecormon 12 5 6  $    1,255.14 
5729M EPOETIN BETA Injection 10,000 units in 0.6 mL pre-filled syringe NeoRecormon 12 5 6  $    1,970.30 
5730N EPOETIN BETA Injection 20,000 units in 0.6 mL pre-filled syringe NeoRecormon 12 5 6  $    3,876.00 
9668W EPOETIN LAMDA Injection 1,000 units in 0.5 mL pre-filled syringe Novicrit 12 5 6  $        264.60
9669X EPOETIN LAMDA Injection 2,000 units in 1 mL pre-filled syringe Novicrit 12 5 6  $        489.60
9670Y EPOETIN LAMDA Injection 3,000 units in 0.3 mL pre-filled syringe Novicrit 12 5 6  $        631.80
9587N EPOETIN LAMDA Injection 4,000 units in 0.4 mL pre-filled syringe Novicrit 12 5 6  $        804.60
9589Q EPOETIN LAMDA Injection 5,000 units in 0.5 mL pre-filled syringe Novicrit 12 5 6  $      1001.70
9591T EPOETIN LAMDA Injection 6,000 units in 0.6 mL pre-filled syringe Novicrit 12 5 6  $      1189.08
9594Y EPOETIN LAMDA Injection 8,000 units in 0.8 mL pre-filled syringe Novicrit 12 5 6  $      1542.24
9596C EPOETIN LAMDA Injection 10,000 units in 1 mL pre-filled syringe Novicrit 12 5 6  $      1866.60
5731P EPOPROSTENOL SODIUM* Powder for I.V. infusion 500 micrograms (base) with diluent Flolan 1 0 1  $          41.69 
5732Q EPOPROSTENOL SODIUM* Powder for I.V. infusion 1.5 mg (base) with diluent Flolan 1 0 1  $          83.37 
5030R

EPOPROSTENOL SODIUM*

 Powder for I.V. infusion 500 mcg (base) infusion administration set          
5035B EPOPROSTENOL SODIUM* Powder for I.V. infusion 1.5 mg (base) infusion administration set Flolan Kit 1 0 1  $          83.37 
5733R ETANERCEPT* Injections 50 mg in 1 mL single use pre-filled syringes, 4 Enbrel 1 0 1  $    1,630.01 
5734T ETANERCEPT* Injection set containing 4 vials powder for injection 25 mg and 4 pre-filled syringes solvent 1 mL Enbrel 1 0 1  $       815.00 
5735W ETANERCEPT* Injection 50 mg in 1 mL single use auto-injector, 4 Enbrel 1 0 1  $    1,630.01 
5736X ETRAVIRINE Tablet 100 mg Intelence 240 5 120  $    1,233.00 
5084N ETRAVIRINE Tablet 200 mg Intelence 120 5 60  $    1,233.00 
5737Y EVEROLIMUS Tablet 1 mg Certican 240 5 60  $    3,844.80 
5738B EVEROLIMUS Tablet 0.25 mg Certican 120 5 60  $       480.60 
5739C EVEROLIMUS Tablet 0.5 mg Certican 120 5 60  $       961.20 
5740D EVEROLIMUS Tablet 0.75 mg Certican 240 5 60  $    2,883.60 
5741E FILGRASTIM Injection 300 micrograms in 1 mL Neupogen 20 11 10  $    2,515.54
5742F FILGRASTIM Injection 300 micrograms in 0.5 mL single use pre-filled syringe Neupogen 20 11 10  $    2,515.54
5743G FILGRASTIM Injection 480 micrograms in 1.6 mL Neupogen 20 11 10  $   4,032.58  
5744H FILGRASTIM Injection 480 micrograms in 0.5 mL single use pre-filled syringe Neupogen 20 11 10  $   4,032.58  
9692D FILGRASTIM Injection 300 micrograms in 0.5 mL single use pre-filled syringe Nivestim 20 11 10 $    2,515.54 
9694F FILGRASTIM Injection 480 micrograms in 0.5 mL single use pre-filled syringe Nivestim 20 11 10 $    4,032.58 
5829F FILGRASTIM Injection 120mcg in 0.2mL single use pre-filled syringe Nivestim 20 11 10 $    1,006.22
5746K FOSAMPRENAVIR CALCIUM Tablet 700mg Telzir 120 5 60  $       758.32 
5745J FOSAMPRENAVIR CALCIUM Oral liquid 50 mg (base) per mL, 225 mL Telzir 8 5 1  $       812.48 
5747L FOSCARNET SODIUM I.V. infusion 24 mg per mL, 250 mL Foscavir 6 1 6  $       395.00 
5748M GANCICLOVIR Intravitreal implant 4.5 mg Vitrasert 1 0 1  $    6,000.00 
5749N GANCICLOVIR Powder for I.V. infusion 500 mg (as sodium) Cymevene 10 1 5  $       560.00 
5750P IBANDRONIC ACID Concentrated injection for I.V. infusion 6 mg (as ibandronate sodium monohydrate) in 6 mL Bondronat 1 11 1  $       341.36 
5751Q ILOPROST TROMETAMOL* Solution for inhalation 20 micrograms (base) in 2 mL Ventavis 30 0 30  $    1,076.00 
5752R INDINAVIR SULFATE Capsule 400 mg (base) Crixivan 400 mg 360 5 180  $       910.00 
5753T INFLIXIMAB* Powder for I.V. infusion 100 mg Remicade 1 0 1  $       751.70 
5754W INFLIXIMAB* Powder for I.V. infusion 100 mg Remicade 1 0 1  $       751.70 
5755X INFLIXIMAB* Powder for I.V. infusion 100 mg Remicade 1 0 1  $       751.70 
5756Y INFLIXIMAB* Powder for I.V. infusion 100 mg Remicade 1 0 1  $       751.70 
5757B INFLIXIMAB* Powder for I.V. infusion 100 mg Remicade 1 0 1  $       751.70 
5758C INFLIXIMAB* Powder for I.V. infusion 100 mg Remicade 1 0 1  $       751.70 
9654D INFLIXIMAB* Powder for I.V. infusion 100 mg Remicade 1 0 1  $       751.70 
5759D INTERFERON ALFA-2a Injection 3,000,000 i.u. in 0.5 mL single dose pre-filled syringe Roferon-A 30 5 1  $       894.00 
5760E INTERFERON ALFA-2a Injection 4,500,000 i.u. in 0.5 mL single dose pre-filled syringe Roferon-A 30 5 1  $    1,341.00 
5761F INTERFERON ALFA-2a Injection 6,000,000 i.u. in 0.5 mL single dose pre-filled syringe Roferon-A 30 5 1  $    1,787.40 
5762G INTERFERON ALFA-2a Injection 9,000,000 i.u. in 0.5 mL single dose pre-filled syringe Roferon-A 30 5 1  $    2,681.40 
5763H INTERFERON ALFA-2b Solution for injection 18,000,000 i.u. in 1.2 mL multi-dose injection pen Intron A Redipen 2 5 1  $       357.48 
5764J INTERFERON ALFA-2b Solution for injection 30,000,000 i.u. in 1.2 mL multi-dose injection pen Intron A Redipen 2 5 1  $       595.80 
5765K INTERFERON ALFA-2b Solution for injection 60,000,000 i.u. in 1.2 mL multi-dose injection pen Intron A Redipen 2 5 1  $    1,191.60 
5766L INTERFERON ALFA-2b Solution for injection 18,000,000 i.u. in 3 mL single dose vial Intron A 15 5 1  $    2,681.10 
5767M INTERFERON ALFA-2b Solution for injection 25,000,000 i.u. in 2.5 mL single dose vial Intron A 15 5 1  $    3,723.75 
5768N INTERFERON ALFA-2b Solution for injection 10,000,000 i.u. in 1 mL single dose vial Intron A 15 5 5  $    1,489.50 
5769P INTERFERON GAMMA-1b Injection 2,000,000 i.u. in 0.5 mL Imukin 12 11 6  $    2,721.80 
5770Q LAMIVUDINE Tablet 100 mg Zeffix 56 5 28  $       298.72 
5771R LAMIVUDINE Oral solution 5 mg per mL, 240 mL Zeffix 5 5 1  $       349.55 
5772T LAMIVUDINE Tablet 150 mg 3TC 120 5 60  $       564.00 
5773W LAMIVUDINE Oral solution 10 mg per mL, 240 mL 3TC 8 5 1  $       691.84 
5774X LAMIVUDINE Tablet 300 mg 3TC 60 5 30  $       564.00 
5775Y LAMIVUDINE with ZIDOVUDINE Tablet 150 mg-300 mg Combivir 120 5 60  $    1,157.20 
5776B LANREOTIDE ACETATE Powder for suspension for injection 30 mg (base) with diluent ampoule Somatuline LA 2 11 1  $    1,500.00 
5777C LANREOTIDE ACETATE Injection 60 mg (base) in single dose pre-filled syringe Somatuline Autogel 2 11 1  $    2,690.00 
5778D LANREOTIDE ACETATE Injection 90 mg (base) in single dose pre-filled syringe Somatuline Autogel 2 11 1  $    3,580.00 
5779E LANREOTIDE ACETATE Injection 120 mg (base) in single dose pre-filled syringe Somatuline Autogel 2 11 1  $    4,480.00 
5780F LANTHANUM Chewable tablet 500 mg (as carbonate hydrate) Fosrenol 180 5 90  $       523.54 
5781G LANTHANUM Chewable tablet 750 mg (as carbonate hydrate) Fosrenol 180 5 90  $       790.56 
5782H LANTHANUM Chewable tablet 1000 mg (as carbonate hydrate) Fosrenol 180 5 90  $       890.02 
5783J LENALIDOMIDE* Capsule 5 mg Revlimid 21 0 21  $    5,392.38 
5784K LENALIDOMIDE* Capsule 10 mg Revlimid 21 0 21  $    5,643.33 
5785L LENALIDOMIDE* Capsule 15 mg Revlimid 21 0 21  $    6,581.61 
5786M LENALIDOMIDE* Capsule 25 mg Revlimid 21 0 21  $    6,934.20 
5787N LENOGRASTIM Powder for injection 13,400,000 i.u. (105 micrograms) Granocyte 13 20 11 10  $    1,025.00 
5788P LENOGRASTIM Powder for injection 33,600,000 i.u. (263 micrograms) Granocyte 34 20 11 10  $    2,567.20 
9743T LEVODOPA with CARBIDOPA Intestinal gel 20mg-5mg per mL, 100mL Duodopa 56 5 7 $    11,536.00 
5789Q LOPINAVIR with RITONAVIR Oral liquid 400 mg-100 mg per 5 mL, 60 mL Kaletra 10 5 1  $    1,290.00 
5790R LOPINAVIR with RITONAVIR Tablet 100 mg-25 mg Kaletra 120 5 60  $       342.50 
5791T LOPINAVIR with RITONAVIR Tablet 200 mg-50 mg Kaletra 240 5 120  $    1,370.00 
5792W MARAVIROC Tablet 150 mg Celsentri 120 5 60  $    1,835.40 
5793X MARAVIROC Tablet 300 mg Celsentri 120 5 60  $    1,835.40 
5794Y METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA Injection 30 micrograms in 0.3 mL pre-filled syringe Mircera 2 5 1  $       369.18 
5795B METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA Injection 50 micrograms in 0.3 mL pre-filled syringe Mircera 2 5 1  $       615.30 
5796C METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA Injection 75 micrograms in 0.3 mL pre-filled syringe Mircera 2 5 1  $       896.02 
5797D METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA Injection 100 micrograms in 0.3 mL pre-filled syringe Mircera 2 5 1  $    1,158.82 
5798E METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA Injection 120 micrograms in 0.3 mL pre-filled syringe Mircera 2 5 1  $    1,341.64 
5799F METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA Injection 200 micrograms in 0.3 mL pre-filled syringe Mircera 2 5 1  $    1,924.30 
5800G METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA Injection 360 micrograms in 0.6 mL pre-filled syringe Mircera 2 5 1  $    3,326.52 
9500B MYCOPHENOLATE MOFETIL Powder for oral suspension 1 g per 5 mL, 165 mL CellCept 2 5 1  $       489.02 
9501C MYCOPHENOLATE MOFETIL Capsule 250 mg CellCept 600 5 100  $    1,111.38 
9502D MYCOPHENOLATE MOFETIL Tablet 500 mg CellCept 300 5 50  $    1,111.38 
9503E MYCOPHENOLATE SODIUM Tablet (enteric coated) 180 mg (mycophenolic acid) Myfortic 240 5 120  $       444.56 
9504F MYCOPHENOLATE SODIUM Tablet (enteric coated) 360 mg (mycophenolic acid) Myfortic 240 5 120  $       889.12 
9505G NATALIZUMAB Solution concentrate for I.V. infusion 300 mg in 15 mL Tysabri 1 5 1  $    2,038.46 
9506H NEVIRAPINE Tablet 200 mg Viramune 120 5 60  $       543.16 
9507J NEVIRAPINE Oral suspension 50 mg (as hemihydrate) per 5 mL, 240 mL Viramune 10 5 1  $    1,350.00 
9508K OCTREOTIDE Injection 50 micrograms (as acetate) in 1 mL Hospira Pty Limited 90 11 5  $      619.02 
9508K OCTREOTIDE Injection 50 micrograms (as acetate) in 1 mL Sandostatin 0.05 90 11 5  $      619.02 
9508K OCTREOTIDE Injection 50 micrograms (as acetate) in 1 mL Octreotide MaxRx 90 11 5  $      619.02 
9509L OCTREOTIDE Injection 100 micrograms (as acetate) in 1 mL Hospira Pty Limited 90 11 5  $   1,236.42
9509L OCTREOTIDE Injection 100 micrograms (as acetate) in 1 mL Sandostatin 0.1 90 11 5  $   1,236.42
9509L OCTREOTIDE Injection 100 micrograms (as acetate) in 1 mL Octreotide MaxRx 90 11 5  $   1,236.42
9510M OCTREOTIDE Injection 500 micrograms (as acetate) in 1 mL Hospira Pty Limited 90 11 5  $   6,194.52 
9510M OCTREOTIDE Injection 500 micrograms (as acetate) in 1 mL Sandostatin 0.5 90 11 5  $   6,194.52 
9510M OCTREOTIDE Injection 500 micrograms (as acetate) in 1 mL Octreotide MaxRx 90 11 5  $   6,194.52 
9511N OCTREOTIDE Injection (modified release) 10 mg (as acetate), vial and diluent syringe Sandostatin LAR 1 11 1  $   1,306.86 
9512P OCTREOTIDE Injection (modified release) 20 mg (as acetate), vial and diluent syringe Sandostatin LAR 1 11 1  $   1,739.81 
9513Q OCTREOTIDE Injection (modified release) 30 mg (as acetate), vial and diluent syringe Sandostatin LAR 1 11 1  $   2,177.46 
9745X OMALIZUMAB* Powder for injection 150mg with diluent Xolair 1 0 1  $   425.00
9514R PEGFILGRASTIM Injection 6 mg in 0.6 mL single use pre-filled syringe Neulasta 1 11 1  $    1,925.00 
9515T PEGINTERFERON ALFA-2a Injection 135 micrograms in 0.5 mL single use pre-filled syringe Pegasys 8 5 4  $    2,331.80 
9516W PEGINTERFERON ALFA-2a Injection 180 micrograms in 0.5 mL single use pre-filled syringe Pegasys 8 5 4  $    2,700.46 
9523F RALTEGRAVIR POTASSIUM Tablet 400 mg (base) Isentress 120 5 60  $    1,331.10 
9524G RIBAVIRIN and PEGINTERFERON ALFA-2a Pack containing 168 tablets ribavirin 200 mg and 4 pre-filled syringes peginterferon alfa-2a injection 135 micrograms Pegasys RBV 2 5 1  $    3,072.84 
9525H RIBAVIRIN and PEGINTERFERON ALFA-2a Pack containing 112 tablets ribavirin 200 mg and 4 pre-filled syringes peginterferon alfa-2a injection 180 micrograms Pegasys RBV 2 5 1  $    3,085.28 
9526J RIBAVIRIN and PEGINTERFERON ALFA-2a Pack containing 140 tablets ribavirin 200 mg and 4 pre-filled syringes peginterferon alfa-2a injection 180 micrograms Pegasys RBV 2 5 1  $    3,245.82 
9527K RIBAVIRIN and PEGINTERFERON ALFA-2a Pack containing 168 tablets ribavirin 200 mg and 4 pre-filled syringes peginterferon alfa-2a injection 180 micrograms Pegasys RBV 2 5 1  $    3,406.36 
9529M RIBAVIRIN and PEGINTERFERON ALFA-2b Pack containing 112 capsules ribavirin 200 mg and 4 single use injection pens containing peginterferon alfa-2b powder for injection Pegatron 2 5 1  $    2,119.74 
9530N RIBAVIRIN and PEGINTERFERON ALFA-2b Pack containing 84 capsules ribavirin 200 mg and 4 single use injection pens containing peginterferon alfa-2b powder for injection Pegatron 2 5 1  $    2,422.72 
9531P RIBAVIRIN and PEGINTERFERON ALFA-2b Pack containing 140 capsules ribavirin 200 mg and 4 single use injection pens containing peginterferon alfa-2b powder for injection Pegatron 2 5 1  $    2,707.66 
9534T RIBAVIRIN and PEGINTERFERON ALFA-2b Pack containing 112 capsules ribavirin 200 mg and 4 single use injection pens containing peginterferon alfa-2b powder for injection Pegatron 2 5 1  $    3,099.62 
9536X RIBAVIRIN and PEGINTERFERON ALFA-2b Pack containing 140 capsules ribavirin 200 mg and 4 single use injection pens containing peginterferon alfa-2b powder for injection Pegatron 2 5 1  $    3,491.58 
9538B RIBAVIRIN and PEGINTERFERON ALFA-2b Pack containing 140 capsules ribavirin 200 mg and 4 single use injection pens containing peginterferon alfa-2b powder for injection Pegatron 2 5 1  $    4,079.52 
9539C RIBAVIRIN and PEGINTERFERON ALFA-2b Pack containing 168 capsules ribavirin 200 mg and 4 single use injection pens containing peginterferon alfa-2b powder for injection Pegatron 2 5 1  $    4,079.52 
9540D RIBAVIRIN and PEGINTERFERON ALFA-2b Pack containing 196 capsules ribavirin 200 mg and 4 single use injection pens containing peginterferon alfa-2b powder for injection Pegatron 2 5 1  $    4,364.48 
9541E RIFABUTIN Capsule 150 mg Mycobutin 120 5 30  $       588.00 
9542F RITONAVIR Oral solution 600 mg per 7.5 mL (80 mg per mL), 90 mL Norvir 10 5 1  $       910.00 
9660K RITONAVIR Tablet 100mg Norvir 720 5 30  $       982.80 
9544H RITUXIMAB* Solution for I.V. infusion 500 mg in 50 mL Mabthera 1 0 1  $    2,263.57 
9696H ROMIPLOSTIM* Powder for injection 375mcg (250mcg in 0.5mL when reconstituted) Nplate 1 0 1  $      977.50
9698K ROMIPLOSTIM* Powder for injection 625mcg (500mcg in 1mL when reconstituted) Nplate 1 0 1  $    1955.00
9545J SAQUINAVIR MESYLATE Tablet 500 mg (base) Invirase 240 5 120  $    1,011.12 
9546K SEVELAMER HYDROCHLORIDE Tablet 800 mg Renagel 360 5 180  $       620.00 
9547L SILDENAFIL CITRATE* Tablet 20 mg (base) Revatio 90 0 90  $       898.43 
9548M SIROLIMUS Tablet 2 mg Rapamune 200 5 100  $    2,893.34 
9549N SIROLIMUS Tablet 1 mg Rapamune 200 5 100  $    1,446.66 
9747B SIROLIMUS Tablet 0.5 mg Rapamune 200 5 100  $    723.34 
9550P SIROLIMUS Oral solution 1 mg per mL, 60 mL Rapamune 2 5 1  $       936.00 
9553T STAVUDINE Capsule 20 mg Zerit 120 5 60  $       560.00 
9554W STAVUDINE Capsule 30 mg Zerit 120 5 60  $       667.36 
9556Y STAVUDINE Capsule 40 mg Zerit 120 5 60  $       889.80 
9558C TACROLIMUS Capsule 500 micrograms Prograf, 200 5 100  $       327.84 
Tacrolimus Sandoz
9560E TACROLIMUS Capsule 1 mg Prograf, 200 5 100  $       655.68 
Tacrolimus Sandoz
9561F TACROLIMUS Capsule 5 mg Prograf, 100 5 50  $    1,638.38 
Tacrolimus Sandoz
9664P TACROLIMUS Capsule 0.5 mg (once daily prolonged relief) Prograf XL 60 5 30  $       98.36 
9665Q TACROLIMUS Capsule 1 mg(once daily prolonged relief) Prograf XL 120 5 30  $       393.40 
9666R TACROLIMUS Capsule 5 mg (once daily prolonged relief) Prograf XL 60 5 30  $     983.54 
9562G TELBIVUDINE Tablet 600 mg Sebivo 56 5 28  $       501.76 
9563H TENOFOVIR Tablet containing tenofovir disoproxil fumarate 300 mg Viread 60 5 30  $       966.20 
9564J TENOFOVIR with EMTRICITABINE Tablet containing tenofovir disoproxil fumarate 300 mg with emtricitabine 200 mg Truvada 60 5 30  $    1,530.20 
9565K TENOFOVIR with EMTRICITABINE and EFAVIRENZ Tablet containing tenofovir disoproxil fumarate 300 mg with emtricitabine 200 mg and efavirenz 600 mg Atripla 60 5 30  $    2,435.48 
9566L THALIDOMIDE Capsule 50 mg Thalomid 112 0 28  $    1,680.00 
9667T THALIDOMIDE Capsule 100mg Thalomid 56 0 28  $    1,680.00 
9567M TIPRANAVIR Capsule 250 mg Aptivus 240 5 120  $    2,142.00 
9656F TIPRANAVIR Oral liquid 100mg per mL, 95mL Aptivus 7 5 1  $    2,374.05 
9657G TOCILIZUMAB* Concentrate for injection 80mg in 4mL Actemra 1 0 1  $       186.88 
9658H TOCILIZUMAB* Concentrate for injection 200mg in 10mL Actemra 1 0 1  $       467.20 
9657G TOCILIZUMAB* Concentrate for injection 400mg in 20mL Actemra 1 0 1  $       934.40 
9568N VALACICLOVIR HYDROCHLORIDE Tablet 500 mg ((as hydrochloride)) Valtrex, APO-Valaciclovir, Zelitrex. Valaciclovir RBX, Valvala 500 2 100  $    2,115.90 
9569P VALGANCICLOVIR HYDROCHLORIDE Tablet 450 mg (base) Valcyte 120 5 60  $    4,491.60 
9655E VALGANCICLOVIR HYDROCHLORIDE Powder for oral solution 50mg (base) per mL, 100ml Valcyte 11 5 1  $    4,574.59 
9570Q ZIDOVUDINE Syrup 10 mg per mL, 200 mL Retrovir 15 5 1  $       673.20 
9651Y ZIDOVUDINE Capsule 100 mg Retrovir 400 5 100  $       821.84 
9652B ZIDOVUDINE Capsule 250 mg Retrovir 240 5 60  $    1,232.76 
9653C ZOLEDRONIC ACID Injection concentrate for I.V. infusion 4 mg (as monohydrate) in 5 mL Zometa 1 11 1  $       450.00 


Special Authority Program (for information only not a HSD)

9689Y TRASTUZUMAB* Powder for I.V. infusion 150 mg Herceptin 1 0 1  $    1,030.21
9690B TRASTUZUMAB* Powder for I.V. infusion 60mg Herceptin 1 0 1  $    412.08

 

* Hospitals claim reimbursement for this item directly via Medicare Australia

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Contact: Michael Furey Tel (03) 9096 2506 Fax (03) 9096 9205

Last updated: 5 January, 2012
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